Incident Log
Date of incident: 26/02/2020
Error type: dispensing error
Patient age: 10
Patient sex: female
Brief summary of incident: Counselling on the maximum number of doses per day resulted in wrong guidance. Four times daily is not automatically accepted number of doses with a regimen of four to six hours.
Name of medication: Oxynorm 5mg/5ml SF Oral Solution;
Level of harm that could have occurred: 3
The reason you think the potential harm is at the level you have chosen:
Pain could go uncontrolled leading to poor quality of life during palliative car.
Possible cause/contributory factors: Unsure of dosing guidelines for oxynorm.
Reasons why incident occurred and actions required to prevent reoccurence:
Need to take a more holistic approach re-pain levels recently as guidance
Best description of this error/near miss:
verbal direction to patient wrong or omitted
Error type: dispensing error
Patient age: 10
Patient sex: female
Brief summary of incident: Counselling on the maximum number of doses per day resulted in wrong guidance. Four times daily is not automatically accepted number of doses with a regimen of four to six hours.
Name of medication: Oxynorm 5mg/5ml SF Oral Solution;
Level of harm that could have occurred: 3
The reason you think the potential harm is at the level you have chosen:
Pain could go uncontrolled leading to poor quality of life during palliative car.
Possible cause/contributory factors: Unsure of dosing guidelines for oxynorm.
Reasons why incident occurred and actions required to prevent reoccurence:
Need to take a more holistic approach re-pain levels recently as guidance
Best description of this error/near miss:
verbal direction to patient wrong or omitted